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TRICARE® Autism Care Demonstration: Transition to Category I CPT® Codes

Tuesday, January 15, 2019

TRICARE has adopted the American Medical Association's new Current Procedural Terminology (CPT®) Category I codes for applied behavior analysis (ABA) services, effective for dates of service on or after Jan. 1, 2019. Please visit the ABA Billing page for the latest information and to download the latest Question & Answer and CPT® Crosswalk documents provided by the Defense Health Agency. 

Key changes

  • Certain services previously billed as untimed, are now timed. 
  • Category I codes are billed in 15-minute increments, rather than 30-minute increments. 
  • Supervision (as previously billed under 0360T/0361T) of behavior technicians and assistant behavior analysts is no longer reimbursable under TRICARE. The Defense Health Agency (DHA) will rely on the supervision requirements of the credentialing entities to ensure that appropriate levels of supervision are still delivered. 
  • DHA has authorized an additional 16 units of 97155 per month per beneficiary through the end of the current authorization to allow providers adequate time to evaluate the tasks allowed under 97155 and determine beneficiary needs prior to the next authorization period. Providers who want to modify the recommended units for 97155 can do so in the treatment plan at the next authorization period.  
  • Health Net Federal Services, LLC (HNFS) will be issuing updated authorizations.

Claim reviews
HNFS will be carefully reviewing each claim for ABA services submitted on or after Jan. 1, 2019, to ensure accurate payment. While these comprehensive claim reviews may shift the processing time for ABA claims, HNFS will continue to meet the contract standard of 98 percent of claims processed within 30 calendar days from receipt date.   

Concurrent care
Concurrent billing is excluded for all ABA Category I CPT® codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. The ABA provider must document on the claim the session time and the presence or absence of the beneficiary, or the claim will deny: 

  • For an EDI claim, use Loop 2300 for header notes or Loop 2400 for individual line notes.
  • For XpressClaims®, enter header notes or individual line notes.

Reimbursement rates
Reimbursement rates have not changed as a result of this CPT® code transition. For the conversion of rates based on the new billing increments, visit the ABA Billing page. 

Updates to existing authorizations
HNFS is converting existing authorizations for ABA care from Category III to Category I codes and will issue updated authorizations to impacted beneficiaries and providers by Feb. 14, 2019. If the care started prior to Jan. 1, 2019, authorized Category III codes will be end dated Dec. 31, 2018. The new Category I codes will start Jan. 1, 2019, and remain valid through the current authorization period. 

  • HNFS will include the additional 16 units per month of 97155 allowed by DHA through the end of the current authorization period on all applicable authorizations. 
  • As of Jan. 1, 2019, HNFS cannot authorize supervision of assistant behavior analysts and behavior technicians, as these services are no longer reimbursable under the Autism Care Demonstration.  
  • Please visit the ABA Billing page to view the Category III to Category I code conversion table. 
  • If after Feb. 14, 2019, you need an additional copy of the updated authorization, use the Check Authorization Status tool to view and print a copy. If you need additional support, please call HNFS’ dedicated Autism Care Demonstration line at 1-844-866-WEST (1-844-866-9378) and select the ABA benefit option. 

Treatment plans
All requests for services (initial and ongoing) submitted on or after Jan. 1, 2019, must specify Category I codes and units. HNFS will only authorize to what is documented in the treatment plan. Please update any treatment plan templates to ensure all recommendations are listed in units, not hours. The units submitted on your online request must match the units documented in the treatment plan. ABA treatment plans submitted after Jan. 1, 2019, without Category I codes and units will not be accepted. 

Online authorization submissions
All requests for authorization must be submitted online. Providers no longer need to attach HNFS’ Initial ABA TRICARE Service Request Forms and Ongoing ABA TRICARE Service Request Form, as these forms have been phased out. 

Medical documentation
The rendering provider must complete medical documentation for all sessions at the time of service, including the start and end time of the session for all CPT® codes on the claim. Additionally, when billing 97155, providers must document who was present and what was demonstrated to whom (such as, modification to error correction procedure modeled to behavior technician). Providers must include session notes for each occurrence of 97151 billed. Please review the medical documentation requirements chart on the ABA Medical Documentation Requirements page.

Please visit our ABA Details page for additional benefit details.